Is early endoscopic retrograde cholangiopancreatography useful in the management of acute biliary pancreatitis?: A meta-analysis of randomized controlled trials

AIMS: To compare early endoscopic retrograde cholangiopancreatography with conservative management for the treatment of acute biliary pancreatitis: a meta-analysis of prospective randomized trials. METHOD: Pertinent studies were selected from the Medline, Embase, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. The rate difference (95% CI) and the number needed to treat were used as a measure of the therapeutic effect. RESULTS: Five prospective randomized trials including 702 patients were selected. Overall complications and mortality rates were 31% and 6%, respectively. In predicted severe pancreatitis the pooled rate difference for complications in early endoscopic retrograde cholangiopancreatography was 38.5% (95% CI -53% to -23.9%); p < 0.0001; number needed to treat = 3. In predicted mild pancreatitis the pooled rate difference for complications in early endoscopic retrograde cholangiopancreatography was 1.8% (95% CI -5.6% to 9.3%); p = 0.6. No mortality was observed in predicted mild pancreatitis. In predicted severe pancreatitis the pooled rate difference for mortality in the early endoscopic retrograde cholangiopancreatography group was 4.3% (95% CI -16% to 7.5%); p < 0.24. CONCLUSIONS: Early endoscopic retrograde cholangiopancreatography reduces pancreatits-related complications in patients with predicted severe pancreatitis although mortality rate is not affected. In predicted mild pancreatitis early endoscopic retrograde cholangiopancreatography has no advantage compared to conservative management.     

Practice efficiency and economics: the case for rapid recovery sedation agents for colonoscopy in a screening population

GOAL: To determine rapidly acting agents' impact on practice efficiency and cost for outpatient colonoscopy in a screening population. BACKGROUND: Propofol-mediated endoscopic sedation is popular due to rapid sedation onset and superior recovery profile compared with sedation with an opioid and benzodiazepine. There are few data on the impact of this type of sedation on the economics and efficiency of an endoscopy unit. STUDY: A provider-perspective economic model assessed the ability of propofol and fospropofol disodium (Aquavan, GPI 15715, MGI Pharma) to increase practice efficiency and determined break-even costs based on current colonoscopy reimbursement levels. Reimbursement inputs by practice setting, costs, and recovery profiles-taken from published literature examining time to discharge-were used to populate the model. To measure robustness of model results to changes in base case inputs, sensitivity analyses were performed. Using a Monte Carlo simulation, inputs were varied simultaneously and randomly for 1000 iterations to determine 95% confidence intervals (CI) for break-even costs. RESULTS: In the time to complete 1 colonoscopy with midazolam/meperidine, 1.76 colonoscopies can be completed with propofol and 1.91 colonoscopies can be completed with fospropofol disodium. This efficiency benefit produced a break-even cost for rapid recovery agents of $71.53 (95% CI: $38.39, $105.67) in a hospital outpatient clinic and $61.48 (95% CI: $41.33, $108.99) in an ambulatory surgical center. One-way sensitivity analyses indicated the break-even cost of these agents was most sensitive to operating costs and time to discharge ratio. CONCLUSIONS: Rapid recovery agents for colonoscopy can improve practice efficiency and offer economic advantages over traditional sedation.     

Racial disparities in the management of hospitalized patients with cirrhosis and complications of portal hypertension: a national study

Having complications of portal hypertension is a harbinger of decompensated cirrhosis and warrants consideration for liver transplantation (LT). Racial disparities in LT have been reported. We sought to characterize disparities in the performing of surgical and endoscopic procedures among hospitalized patients with complications of portal hypertension. We queried the Nationwide Inpatient Sample from 1998 to 2003 to identify patients with cirrhosis and complications of portal hypertension. Logistic regression controlling for confounders was used to evaluate race as a predictor of undergoing a portosystemic shunt and LT and of dying in the hospital. Compared to whites, the adjusted odds ratios of receiving a portosystemic shunt were 0.37 (95% CI: 0.27-0.51) and 0.69 (95% CI: 0.54-0.88) for African Americans (AAs) and Hispanics, respectively. AAs with variceal bleeding were more likely to have endoscopic variceal hemostasis delayed more than 24 hours after admission than were whites (OR 1.6; 95% CI: 1.2-2.1). The adjusted odds ratios of undergoing LT were 0.32 (95% CI:0.20-0.52) and 0.46 (95% CI: 0.25-0.83) for AAs and Hispanics, respectively. Compared to whites, AAs experienced higher in-hospital mortality (OR 1.12; 95% CI: 1.01-1.24), whereas Hispanics had a lower risk of death (OR 0.83; 95% CI: 0.75-0.92). Among variceal bleeders, the odds ratio of death for AAs was 1.7 (95% CI: 1.2-2.4) compared to whites. CONCLUSION: AAs and Hispanics hospitalized for complications of portal hypertension were less likely to undergo a palliative shunt or LT than whites, which may contribute to the higher in-hospital mortality of AAs. Further studies are warranted to elucidate the mechanisms of these exploratory findings.     

Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update

GOALS: The aim of this study was to determine through meta-analysis the effects of transjugular intrahepatic portosystemic shunt (TIPS) for the reduction of variceal rebleeding (VRB). BACKGROUND: Variceal bleeding is one of the most frequent and severe complications of chronic liver disease. Although prophylactic use of TIPS for the reduction of VRB has been evaluated, the discrepancy about TIPS's beneficial effect on cirrhotic patients still exists. STUDY: We employed the method recommended by the Cochrane Collaboration to perform a meta-analysis of randomized controlled trials (RCTs) of TIPS versus endoscopic therapy in the prevention of VRB including 12 RCTs conducted in 7 different countries. RESULTS: Most RCTs reviewed were of high quality. The updated meta-analysis showed that the decreased incidence of VRB [odds ratio (OR)=0.32, 95% confidence interval (CI) (0.24-0.43), P<0.00001], deaths due to rebleeding [OR=0.35, 95% CI (0.18-0.67), P=0.002], the increased rate of posttreatment encephalopathy [OR=2.21, 95% CI (1.61-3.03), P<0.00001] were correlated with TIPS, whereas the hospitalization days [weighted mean difference=-0.21, 95% CI (-3.50 to 3.08), P=0.90] and deaths due to all causes [OR=1.17, 95% CI (0.85-1.61), P=0.33] returned negative results in 2 groups. CONCLUSIONS: TIPS is currently the first choice to prevent rebleeding except that TIPS is worse than endoscopic therapy for encephalopathy. An exploration of new approaches out of above complications will be of considerable clinical significance and be a challenge to clinicians.     

Factors associated with incomplete colonoscopy: a population-based study

BACKGROUND & AIMS: The U.S. Multi-Society Task Force on Colorectal Cancer sets a target of cecal intubation in at least 90% of colonoscopies. We conducted a population-based study to determine the colonoscopy completion rate and to identify factors associated with incomplete procedures. METHODS: Men and women 50 to 74 years of age who underwent a colonoscopy in Ontario between January 1, 1999, and December 31, 2003, were identified. The first (index) colonoscopy was classified as complete or incomplete. A generalized estimating equations model was used to evaluate the association between patient, endoscopist (specialty, colonoscopy volume), and setting (academic hospital, community hospital, private office) factors and incomplete colonoscopy. RESULTS: A total of 331,608 individuals had an index colonoscopy, of which 43,483 (13.1%) were incomplete. Patients with an incomplete colonoscopy were older (odds ratio [OR] 1.20 per 10-year increment; 95% confidence interval [CI]=1.18-1.22), more likely to be female (OR 1.35; 95% CI: 1.30-1.39), have a history of prior abdominal surgery (OR 1.07; 95% CI: 1.05-1.09) or prior pelvic surgery (OR 1.04; 95% CI: 1.01-1.06). For colonoscopies done in a private office, the odds of an incomplete procedure were more than 3-fold greater than for procedures done in an academic hospital (OR 3.57; 95% CI: 2.55-4.98). CONCLUSIONS: In usual clinical practice in Ontario, 13.1% of colonoscopies are incomplete. The factors most strongly associated with incomplete colonoscopy were increased patient age, female sex, and having the procedure in a private office. Quality improvement programs are needed to improve colonoscopy completion rates.     

No increased risk of perforation during colonoscopy in patients undergoing propofol versus traditional sedation: A meta-analysis

Background and Aims

The safety of propofol sedation during colonoscopy remains unclear, and we performed a meta-analysis to assess the risk of perforation in patients undergoing propofol vs. traditional sedation.

Methods

MEDLINE, CBM, VIP, CNKI, and Wanfang databases were searched up to December 2016. Two reviewers independently assessed abstract of those searched articles. Data about perforation condition in propofol and traditional sedation groups were extracted and combined using the random effects model.

Results

A total of 19 studies were included in the current meta-analysis. Compared to traditional sedation, propofol sedation did not increase the risk of perforation (RD?=???0.00, 95% CI ??0.00~0.00, p?=?0.98; subgroup analysis: OR?=?1.30, 95% CI 0.83~2.05, p?=?0.25).

Conclusion

This meta-analysis suggested that propofol sedation did not increase the risk of perforation compared to traditional sedation during colonoscopy.

     

Nurse-administered propofol sedation for upper endoscopic ultrasonography

BACKGROUND: Limited data exist regarding the safety of nurse-administered propofol sedation (NAPS) for advanced endoscopy.
AIMS: To evaluate the frequency of and the risk factors for complications associated with NAPS for upper endoscopic ultrasound (EUS).
METHODS: Consecutive upper EUS examinations using NAPS were retrospectively identified. Clinical data and adverse events were recorded. Univariate and multivariable repeated measures logistic regression models were used to identify independent risk factors for complications.
RESULTS: Among 806 EUS procedures, the mean procedure duration, time for sedation induction, and postprocedure recovery time were: 34 ± 20 min, 3.6 ± 1.4 min, and 27 ± 23 min, respectively. A decline in systolic blood pressure (SBP) to <90 mm Hg occurred in 104 patients (13%). Six patients (0.7%) had a decline in oxygen saturation (SpO₂) to <90%. Four patients (0.5%; 95% confidence interval [CI] 0.14–1.27) required assisted positive pressure ventilation. There were no major complications. The minor complication rate from sedation was 21% (95% CI 17.2–25.3). All of the complications were clinically insignificant. Overall complication risk was not related to age, dose, or procedure time. Sedation-related complication rates for advanced experience-level (≥100 NAPS procedures) nurses were lower compared to the least-experienced (≤30 NAPS procedures) nurses (17.2% vs 25.4%, odds ratio [OR] 0.61, 95% CI 0.41–0.92).
CONCLUSIONS: NAPS for upper EUS is safe and may be performed without major complications. Four patients (0.5%) required assisted ventilation. Minor complications occurred in 21% of patients, but were not associated with patient age, propofol dose, or procedure time.     

Preoperative endoscopic stent placement before pancreaticoduodenectomy: a meta-analysis of the effect on morbidity and mortality

BACKGROUND: Pancreaticoduodenectomy is the only potentially curative treatment for peripapillary pancreatic tumors. However, postoperative morbidity and mortality are high, and different approaches have been tried to improve results, such as preoperative biliary drainage in patients with jaundice. This meta-analysis investigated the effect on postoperative outcome of preoperative biliary drainage by endoscopic biliary stent placement in patients who are jaundiced and who have peripapillary pancreatic tumors. METHODS: A Medline search for the period 1985 to 2001 was performed. Eight retrospective studies and 2 prospective randomized controlled trials were included. Selection criteria for the primary analysis were as follows: patients with peripapillary pancreatic cancer, endoscopic stent placement versus no stent, radical surgery, and assessment of postoperative morbidity and mortality. A secondary analysis included both radical and palliative surgery. RESULTS: In the primary analysis, 337 patients underwent preoperative endoscopic biliary stent placement, and 412 patients had no endoscopic biliary stent placement (controls). The overall odds ratio for postoperative complications (stent vs. no stent) is estimated as 0.79: 95% CI [0.36, 1.73] and the estimated odds ratio for postoperative mortality is 0.81: 95% CI [0.33, 1.99]. In the secondary analysis, 1008 patients underwent preoperative EBS versus 720 control patients. The odds ratio for postoperative complications in this analysis was 0.93: 95% CI [0.65, 1.33] and for postoperative mortality is 1.12: 95% CI [0.62, 2.01]. CONCLUSION: No evidence was found of either a positive or adverse effect of preoperative endoscopic biliary stent placement on the outcome of surgery in patients with pancreatic cancer.     

Detection of proximal adenomatous polyps with screening sigmoidoscopy: a systematic review and meta-analysis of screening colonoscopy

BACKGROUND: The relative effectiveness of flexible sigmoidoscopy compared with colonoscopy to screen for colorectal cancer depends on the magnitude of the association between findings in the proximal and distal colon and the false-negative rate of screening sigmoidoscopy for proximal neoplasia. To address this, we performed a systematic review and meta-analysis of screening colonoscopy studies. METHODS: Published studies through July 31, 2000, of asymptomatic patients undergoing screening colonoscopy were identified from the MEDLINE database. We generated pooled estimates of the odds ratio for the association between findings in the distal and proximal colon and the prevalence of isolated proximal adenomatous neoplasia. RESULTS: Using the sigmoid-descending colon junction to identify the beginning of the distal colon, the pooled odds ratio for the association between distal adenomatous polyps and any proximal neoplasia was 2.40 (95% confidence interval [CI], 1.42-4.05). Diminutive distal adenomatous polyps were also associated with proximal neoplasia (odds ratio, 2.36; 95% CI, 1.30-4.29). Distal hyperplastic polyps were not associated with proximal neoplasia (odds ratio, 1.44; 95% CI, 0.79-2.62). The prevalence of isolated advanced proximal neoplasia in the 3 studies was 2%, 3%, and 5%. Using the sigmoid-descending colon junction to identify the beginning of the distal colon yields a pooled estimate of isolated proximal neoplasia of 16.3% (95% CI, 13.6%-19.1%). CONCLUSIONS: Distal adenomatous polyps, including diminutive distal adenomatous polyps, are associated with an increased prevalence of synchronous proximal neoplasia. Two percent to 5% of patients undergoing screening colonoscopy may have isolated advanced proximal neoplasia. Even more patients may have isolated nonadvanced proximal neoplasia.     

A national study of cardiopulmonary unplanned events after GI endoscopy

BACKGROUND: Cardiopulmonary unplanned events (CUE) related to conscious sedation constitute a major proportion of GI endoscopy-associated complications. OBJECTIVES: Our purpose was to study the incidence of CUE during GI endoscopy and to determine factors that may predict CUE. DESIGN: Retrospective CORI (Clinical Outcomes Research Initiative) database review. PATIENTS: Undergoing GI endoscopy under conscious sedation. MAIN OUTCOME MEASUREMENT: CUE associated with GI endoscopy. RESULTS: Data on 324,737 unique procedures (EGD, 140,692; colonoscopy, 174,255; ERCP, 6092; and EUS, 3698) performed with the patient under conscious sedation were analyzed. Unplanned events were reported in 1.4% of procedures; 0.9% were associated with CUE. Rates of CUE with EGD, colonoscopy, ERCP, and EUS were 0.6%, 1.1%, 2.1%, and 0.9%, respectively. Multiple logistic regression revealed patient age (odds ratio [OR] 1.02, 95% CI 1.01-1.02) and ASA class were significant predictors of CUE (OR compared with ASA I: ASA II 1.05, 95% CI 0.95-1.16; ASA III 1.8, 95% CI 1.6-2.0, ASA IV 3.2, 95% CI 2.5-4.1, ASA V 7.5; 95% CI 3.2-17.6). Inpatient procedures were associated with higher CUE (OR 1.5, 95% CI 1.3-1.7). Compared with universities, nonuniversity sites (OR 1.2, 95% CI 1.1-1.4) and Veterans Administration Medical Centers (OR 1.4, 95% CI 1.2-1.5) had significantly higher CUE. Use of supplemental oxygen during a procedure was associated with significantly more CUE (OR 1.2, 95% CI 1.1-1.3). Involvement of a trainee with a procedure was also associated with higher CUE (OR 1.3, 95% CI 1.1-1.4). LIMITATIONS: Retrospective review of data entered voluntarily by endoscopists not trained on CORI data entry. CONCLUSIONS: During GI endoscopy with conscious sedation, patient's age, higher ASA grade, inpatient status, trainee participation, and routine use of oxygen are associated with a higher incidence of CUE.     

Use of the Endocuff during routine colonoscopy examination improves adenoma detection: A meta-analysis

AIM To perform meta-analysis of the use of Endocuff during average risk screening colonoscopy.METHODS Scopus, Cochrane databases, MEDLINE/Pub Med, and CINAHL were searched in April 2016. Abstracts from Digestive Disease Week, United European Gastroenterology, and the American College of Gastroenterology meeting were also searched from 2004-2015. Studies comparing EC-assisted colonoscopy(EAC) to standard colonoscopy, for any indication, were included in the analysis. The analysis was conducted by using the Mantel-Haenszel or DerS imonian and Laird models with the odds ratio(OR) to assess adenoma detection, cecal intubation rate, and complications performed. RESULTS Nine studies(n = 5624 patients) were included in the analysis. Compared to standard colonoscopy, procedures performed with EC had higher frequencies for adenoma(OR = 1.49, 95%CI: 1.23-1.80; P = 0.03), and sessile serrated adenomas detection(OR = 2.34 95%CI: 1.63-3.36; P 0.001). There was no significant difference in cecal intubation rates between the EACgroup and standard colonoscopy(OR = 1.26, 95%CI: 0.70-2.27, I2 = 0%; P = 0.44). EAC was associated with a higher risk of complications, most commonly being superficial mucosal injury without higher frequency for perforation.CONCLUSION The use of an EC on colonoscopy appears to improve pre-cancerous polyp detection without any difference in cecal intubation rates compared to standard colonoscopy.     

Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia

BACKGROUND: Suboptimal bowel preparation for colonoscopy can lead to missed colonic lesions. The aim of this study was to describe the impact of preparation quality on detection of suspected colonic neoplasia. METHODS: Data from the Clinical Outcomes Research Initiative national endoscopic database for the period January 1, 2000 to December 31, 2001, were analyzed. Patient demographics, quality of preparation, and colonoscopy findings were abstracted from the database. RESULTS: Overall, 93,004 colonoscopies with adequate documentation were reviewed. Preparation was adequate for 71,501 (76.9%) of these procedures. On multivariate analysis, preparation adequacy was associated with colonic lesion detection, odds ratio (OR) 1.21: 95% CI [1.16, 1.25]. Adequate preparation demonstrated a closer association with identification of "nonsignificant" lesions (polyps 9 mm), OR 1.05: 95% CI [0.98, 1.11]. CONCLUSIONS: Bowel preparation is inadequate for almost a quarter of patients undergoing colonoscopy. These results suggest that inadequate preparation quality only hinders detection of smaller lesions, while having negligible impact on detection of larger lesions. These results should be confirmed in prospective studies.     

Predictive value of diminutive colonic adenoma trial: the PREDICT trial.

BACKGROUND & AIMS: Diminutive adenomas (1-9 mm in diameter) are frequently found during colon cancer screening with flexible sigmoidoscopy (FS). This trial assessed the predictive value of these diminutive adenomas for advanced adenomas in the proximal colon. METHODS: In a multicenter, prospective cohort trial, we matched 200 patients with normal FS and 200 patients with diminutive adenomas on FS for age and gender. All patients underwent colonoscopy. The presence of advanced adenomas (adenoma >or= 10 mm in diameter, villous adenoma, adenoma with high grade dysplasia, and colon cancer) and adenomas (any size) was recorded. Before colonoscopy, patients completed questionnaires about risk factors for adenomas. RESULTS: The prevalence of advanced adenomas in the proximal colon was similar in patients with diminutive adenomas and patients with normal FS (6% vs. 5.5%, respectively) (relative risk, 1.1; 95% confidence interval [CI], 0.5-2.6). Diminutive adenomas on FS did not accurately predict advanced adenomas in the proximal colon: sensitivity, 52% (95% CI, 32%-72%); specificity, 50% (95% CI, 49%-51%); positive predictive value, 6% (95% CI, 4%-8%); and negative predictive value, 95% (95% CI, 92%-97%). Male gender (odds ratio, 1.63; 95% CI, 1.01-2.61) was associated with an increased risk of proximal colon adenomas. CONCLUSIONS: Diminutive adenomas on sigmoidoscopy may not accurately predict advanced adenomas in the proximal colon.     

Obesity is a definitive risk factor of severity and mortality in acute pancreatitis: an updated meta-analysis.

BACKGROUND/AIMS: Obesity is considered a risk factor in patients with acute pancreatitis. However, the relationship between obesity and mortality in this disease has not been confirmed definitively even in a previous meta-analysis. Since the publication of our previous meta-analysis, one study has been reported about the prognostic value of obesity in acute pancreatitis. We have performed a new meta-analysis to confirm the relationship between obesity and the outcome of acute pancreatitis. DATA SOURCES: A MEDLINE search using 'pancreatitis', 'obesity' and 'body mass index' as search terms. REVIEW METHODS: Clinical studies which investigated the prognostic value of obesity in acute pancreatitis with the following criteria: (a) inclusion of mild and severe acute pancreatitis; (b) use of body mass index (BMI) as the measure of obesity; (c) definition of obesity as BMI >or=30 kg/m(2); (d) definition of severity of acute pancreatitis according to the criteria established in the Atlanta Symposium. Five studies including patients with mild and severe acute pancreatitis and obesity measured by BMI were analyzed. The end points of the meta-analysis were the severity of acute pancreatitis, local complications, systemic complications and mortality. Pooled odds ratio (OR) and confidence intervals (CI) were calculated according to the Mantel-Haenszel method, and heterogeneity was assessed by the multiplicative inverse variance method. RESULTS: Seven hundred and thirty-nine patients were included. There was no heterogeneity for the variables severity, systemic complications, local complications and mortality among the included studies. Severe acute pancreatitis was significantly more frequent in obese patients (OR 2.9, 95% CI 1.8-4.6). Furthermore, those patients developed significantly more systemic (OR 2.3, 95% CI 1.4-3.8) and especially local complications (OR 3.8, 95% CI 2.4-6.6). In this new analysis, mortality was also higher in obese patients (OR 2.1, 95% CI 1.0-4.8). CONCLUSION: Obesity is not only a risk factor for the development of local and systemic complications in acute pancreatitis: it also increases the mortality of this disease.     

Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

AIM To perform a systematic review and meta-analysis to assess the safety of conscious sedation in patients with obstructive sleep apnea(OSA).METHODS A comprehensive electronic search of MEDLINE and EMBASE was performed from inception until March 1, 2015. In an effort to include unpublished data, abstracts from prior gastroenterological society meetings as well as other reference sources were interrogated. After study selection, two authors utilizing a standardized data extraction form collected the data independently. Any disagreements between authors were resolved by consensus among four authors. The methodological quality was assessed using the Newcastle Ottawa tool for observational studies. The primary variables of interest included incidence of hypoxia, hypotension, tachycardia, and bradycardia. Continuous data were summarized as odds ratio(OR) and 95%CI and pooled using generic inverse variance under the random-effects model. Heterogeneity between pooled studies was assessed using the I2 statistic.RESULTS Initial search of MEDLINE and EMBASE identified 357 citations. A search of meeting abstracts did not yield any relevant citations. After systematic review and exclusion consensus meetings, seven studies met the a priori determined inclusion criteria. The overall methodological quality of included studies ranged from moderate to low. No significant differences between OSA patients and controls were identified among any of the study variables: Incidence of hypoxia(7 studies, 3005 patients; OR = 1.11; 95%CI: 0.73-1.11; P = 0.47; I2 = 0%), incidence of hypotension(4 studies, 2125 patients; OR = 1.10; 95%CI: 0.75-1.60; P = 0.63; I2 = 0%), incidence of tachycardia(3 studies, 2030 patients; OR = 0.94; 95%CI: 0.53-1.65; P = 0.28; I2 = 21%), and incidence of bradycardia(3 studies, 2030 patients; OR = 0.88; 95%CI: 0.63-1.22; P = 0.59; I2 = 0%).CONCLUSION OSA is not a significant risk factor for cardiopulmonary complications in patients undergoing endoscopic procedures with conscious sedation.     

Propofol sedation in outpatient colonoscopy by trained practice nurses supervised by the gastroenterologist: a prospective evaluation of over 3000 cases

BACKGROUND AND STUDY AIMS: Propofol has several advantages for sedation in endoscopic procedures. Sedation administered by anaesthesiologists is associated with high costs. In this study the safety of propofol sedation administered by trained practice nurses under the supervision of the gastroenterologist in a cohort of outpatients of an ambulatory practice for gastroenterology in Germany is evaluated. METHODS: During a period of 21 months all patients referred to colonoscopy were eligible for this prospective observational study. The familiar CRC risk of the individuals, indication, completeness and results of the colonoscopy were registered together with the dose of propofol used. Propofol was administered by intermittent intravenous bolus titration by trained practice nurses under supervision of the gastroenterologist. Oxygen saturation, heart rate and blood pressure were recorded constantly during the procedure and adverse cardiopulmonary events were monitored by the endoscopy team. A respiratory event was defined as an episode of apnoea or laryngospasm requiring assisted ventilation. 23 % of the patients received supplemental oxygen. RESULTS: A total of 3641 colonoscopies were recorded. 33 individuals were sedated with midazolam and were excluded from the evaluation. 3610 individuals were sedated with propofol (119 +/- 39 mg, mean dose +/- S. D.). 40 % of the procedures were performed as combined gastroscopy and colonoscopy. The cecum was reached in 99 % of the colonoscopies. Respiratory events occurred in five patients (0.14 %). Assisted ventilation in all cases was performed by mask ventilation. Bradycardia (HF < 60/min) and arterial hypotension (RR < 90 mmHg) occurred in 0.5 and 0.3 % of the colonoscopies, respectively, but medical intervention was necessary only in 0.2 % for both types of event. Minor events of hypoxaemia were observed in 51 patients (1.4 %), but only 1/3 of these events occurred in patients supplemented with oxygen. CONCLUSIONS: Propofol can be administered safely for ambulatory colonoscopy by trained practice nurses, with careful monitoring under supervision of the gastroenterologist.     

Long term outcome of patients with active Crohn's disease exhibiting extensive and deep ulcerations at colonoscopy

OBJECTIVE: Prediction of the clinical course of Crohn's disease (CD) is difficult in the long term. Our aim was to determine whether the presence of severe endoscopic lesions (SELs) may predict a higher risk of colectomy and penetrating complications. METHODS: All patients at our institution with active ileocoIonic CD who had colonoscopies between 1990 and 1996 were included in the study. SELs were defined as extensive and deep ulcerations covering more than 10% of the mucosal area of at least one segment of the colon. RESULTS: Among the 102 patients included, 53 had SELs at index colonoscopy. During the follow-up (median = 52 months), 37 patients underwent colonic resection. Probabilities of colectomy at 1, 3, and 8 yr were 20%, 26%, and 42%. Risk of colectomy was independently affected by the presence of SELs at index colonoscopy (relative risk [RR] = 5.43, 95% CI = 2.64-11.18), a Crohn's Disease Activity Index level greater than 288 (RR = 2.21, 95% CI = 1.09-4.47), and the absence of immunosuppressive therapy during the follow-up (RR = 2.44, 95% CI = 1.20-5.00). Probabilities of colectomy were, respectively, 31% and 6% at 1 yr, 42% and 8% at 3 yr, and 62% and 18% at 8 yr in patients with and without SELs. We performed a second analysis excluding the 14 patients operated on within the 3 months after the index colonoscopy: presence of SELs remained the only significant factor predictive of colectomy (RR = 6.72, 95% CI = 2.26-20.03). All six patients with penetrating complications during the follow-up had SELs at index colonoscopy. CONCLUSIONS: Patients with CD exhibiting deep and extensive ulcerations at colonoscopy have a more aggressive clinical course with an increased rate of penetrating complications and surgery.     

Colonoscopy screening in African Americans and Whites with affected first-degree relatives

BACKGROUND: Family history is a risk factor for colon cancer, and guidelines recommend initiating screening at age 40 years in individuals with affected relatives. Racial differences in colon cancer mortality could be related to variations in screening of increased-risk individuals. METHODS: Baseline data from 41 830 participants in the Southern Community Cohort Study were analyzed to determine the proportion of colonoscopy procedures in individuals with strong family histories of colon cancer, and whether differences existed based on race. RESULTS: In participants with multiple affected first-degree relatives (FDRs) or relatives diagnosed before age 50 years, 27.3% (95% confidence interval [CI], 23.5%-31.1%) of African Americans reported having a colonoscopy within the past 5 years compared with 43.1% (95% CI, 37.0%-49.2%) of white participants (P<.001). African Americans in this group had an odds ratio of 0.51 (95% CI, 0.38-0.68) of having undergone recommended screening procedures compared with white participants after adjusting for age, sex, educational status, annual income, insurance status, total number of affected and unaffected FDRs, and time since last medical visit. African Americans with multiple affected FDRs or relatives diagnosed before age 50 years and who had ever undergone endoscopy were less likely to report a personal history of colon polyps (odds ratio, 0.29; 95% CI, 0.20-0.42) when compared with whites with similar family histories. CONCLUSIONS: African Americans who have FDRs with colon cancer are less likely to undergo colonoscopy screening compared with whites who have affected relatives. Increased efforts need to be directed at identifying and managing underserved populations at increased risk for colon cancer based on their family histories.     

CT-Base Pulmonary Artery Measurementin the Detection of Pulmonary Hypertension: A Meta-Analysis and Systematic Review

To summarize the performance of CT-based main pulmonary artery diameter or pulmonary artery to aorta ratio (PA:A ratio) measurement in detection of pulmonary hypertension by a systematic review and meta-analysis.A comprehensive literature search was performed to identify studies determining diagnostic accuracy of main pulmonary artery diameter or PA:A ratio measurement for pulmonary hypertension. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the quality of the included studies. A bivariate random-effects model was used to pool sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to summarize overall diagnostic performance.This meta-analysis included 20 publications involving 2134 subjects. Summary estimates for main pulmonary artery diameter measurement in the diagnosis of pulmonary hypertension were as follows: sensitivity, 0.79 (95% CI 0.72–0.84); specificity, 0.83 (95% CI 0.75–0.89); PLR, 4.68 (95% CI 3.13–6.99); NLR, 0.26 (95% CI 0.20–0.33); DOR, 18.13 (95% CI 10.87–30.24); and AUC 0.87. The corresponding summary performance estimates for using the PA:A ratio were as follows: sensitivity, 0.74 (95% CI 0.66–0.80); specificity, 0.81 (95% CI 0.74–0.86); PLR, 3.83 (95% CI, 2.70–5.43); NLR, 0.33 (95% CI 0.24–0.44); DOR, 11.77 (95% CI 6.60–21.00); and AUC 0.84.Both main pulmonary artery diameter and PA:A ratio are helpful for diagnosing pulmonary hypertension. Nevertheless, the results of pulmonary artery measurement should be interpreted in parallel with the results of traditional tests such as echocardiography.     

A comparative study of propofol alone and propofol combined with midazolam for dental treatments in special needs patients

Although dental treatment with sedation is performed increasingly in special needs patients, data on adding midazolam to intravenous propofol sedation are very limited for this group. The purpose of this study was to identify the factors and procedure time associated with the use of intravenous sedation with propofol alone or propofol combined with midazolam in dental patients with special needs.This was a retrospective data analysis. The sedation medications and relevant covariates, including demographic parameters, disability levels, oral health conditions, dental procedures, treatment time, and side effects, of 718 patients with special needs were collected between April 2013 and September 2014. The unfavorable side effects by sedation types were reported. Factors associated with procedure time and the sedation medications were assessed with multiple logistic regression analyses.Of 718 patients, 8 patients experienced unfavorable side effects (vomiting, sleepiness, or emotional disturbance) after the dental procedures; the rate was 0.6% in the 509 patients who received propofol only. In 209 patients who received propofol and midazolam, 2.4% experienced the side effects. Sedation time was associated with body mass index (BMI) < 25 (adjusted odds ratio [aOR] = 1.45, 95% confidence interval [CI]: 1.04–2.04) and the performance of multiple dental procedures (aOR = 1.44, 95% CI: 1.06–1.97) but not associated with the sedation types. A significant odds ratio for the combined use of propofol and midazolam was shown for adolescents (aOR = 2.22, 95% CI: 1.28–3.86), men (aOR = 2.05, 95% CI: 1.41–2.98), patients with cognitive impairment (aOR = 1.99, 95% CI: 1.21–3.29), and patients undergoing scaling procedures (aOR = 1.64, 95% CI: 1.13–2.39).With the acceptable side effects of the use of propofol alone and propofol combined with midazolam, multiple dental procedures increase the sedation time and the factors associated with the combined use of propofol and midazolam are younger age, male sex, recognition problems, and the type dental procedure in the dental treatment of patients with special needs.